The College of Pharmacists of Manitoba (the College) partnered with the Institute for Safe Medication Practices Canada (ISMP Canada) to develop Safety IQ. Safety IQ is a year-long pilot in which community pharmacists report, review and share learnings about why medication errors occur and how they can be prevented.
College of Pharmacists of Manitoba:
To protect the health and well-being of the public by ensuring and promoting safe, patient-centred, and progressive pharmacy practice in collaboration with other health-care providers.
To identify risks in medication use systems, recommend optimal system safeguards, and advance safe medication practices.
Current Practices in Manitoba
When a medication incident occurs in a community pharmacy in Manitoba, pharmacy staff are already required to ensure that:
The patient involved in the incident is safe and has any medical attention they need
The patient receives the right medication in a timely fashion
The patient involved has an opportunity to discuss his/her concerns
All pharmacy staff are informed including managers
The medication prescriber is informed of the error
The medication error is investigated to identify root causes and practice changes are made to prevent a recurrence
Safety IQ adds elements of standardization and shared learning to enhance patient safety and continuous quality improvement.
Safety IQ enables community pharmacies to:
Anonymously report medication incidents and near misses to a central database
Enhance patient safety using standardized tools and practices
Learn from incidents and near misses in other pharmacies
Engage with medication safety experts to improve their processes
Contribute to research that will define and investigate the prevalence and causes of medication incidents in Canada
Promote a culture of safety in which all pharmacy staff feel comfortable reporting and talking about medication incidents
Reporting Across Canada
Nova Scotia: SafetyNET-Rx - Mandatory reporting
Saskatchewan: COMPASS - Mandatory reporting
Prince Edward Island: Pilot (2012 - 2013)
New Brunswick: Pilot (2015-2016)
Manitoba: Safety IQ Pilot (2017 - 2018)
Ontario: Pilot (2017 - 2018)
Rachel Carlson, Communications College of Pharmacists of Manitoba firstname.lastname@example.org 204-233-1411
Continuous Quality Improvement (CQI), is an ongoing approach to problem-solving and harm-prevention that focuses on identifying root causes of a problem and introducing ways to eliminate or reduce the problem.
In the pharmacy profession, CQI focuses on preventing medication incidents and continually looking for ways to improve medication dispensing, therapy management, and patient counselling.
The Safety IQ approach to CQI combines proactive and reactive elements to improve patient safety.
Each participating pharmacy conducts a medication safety self-assessment. ISMP Canada designed the assessment to empower community pharmacy professionals to ask ‘what are we doing now and how can we do better?’
Each participating pharmacy anonymously reports medication incidents and near misses to ISMP Canada. ISMP Canada then shares reports and recommendations with the pharmacies to form the basis of their practice improvements. Each pharmacy conducts quarterly staff meetings to analyze and discuss medication incidents and near misses and the practice changes that have been implemented.
Medication incidents are preventable errors that may result in inappropriate medication use or patient harm. Medication incidents may be related to professional practice, product labelling, dispensing processes or other factors.
A near miss event is an error that could have resulted in inappropriate medication use or patient harm, but was discovered before reaching the patient.
A safety culture is the shared belief and the practice of healthcare providers that makes safety the first priority when providing care to patients. According to the US Institute of Medicine, “the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”
For community pharmacy, a safety culture optimizes learning from medication incidents and near misses to prevent future errors and improve patient safety.